Health examination report

Transcription

1 Health examination report 1. GMC case details 2. Details of the examiner Case reference Your full name 3. Details of the doctor being assessed Full name Date of birth 4. Appointments 5. Examination report Appointment date Date of report 6. Impairing diagnosis(es) Impairing ICD diagnosis(es), if any. 7. Opinion on fitness to practise Please select

2 Introduction This section should include: your brief biography, including your current job title. an overview of documents you have reviewed that were provided by the GMC. a brief description of the circumstances leading to the doctor's referral/self-referral to the GMC. a brief summary of when and why health concerns were reported. reference to the ICD-10 we asked you to comment on.

3 History of presenting illness or circumstances Under this heading, please provide details about: history of the current episode of illness or suspected illness, any treatment and support provided during this period, any effect on the doctor's ability to work/periods of absence, information about current and past use of alcohol and drugs (if relevant to the history of present illness), including engagement with support services and treatment groups. Psychiatric treatment received (current and previous) Use this heading to explore the following, if not covered above: treatments received for this episode, or longer term diagnosis, including response to treatment, and compliance with the treatment plan, if not covered above, any previous diagnoses or contact with any psychiatric or other health services, record as far as possible: date of illness treatments, including symptoms hospitalisation and out-patient diagnoses Medical and surgical history Use this heading to: document any relevant medical and surgical history, any other medication not mentioned already.

4 Relevant personal and family history a brief family history, details of relevant personal, occupational, social, financial, and relationship history, alcohol and substance misuse history, if not covered already. Mental state examination observations on appearance and behaviour, including self-care, thought content, including self-harm, comments on insight. Physical examination details of any physical examination you carried out, comments on self-care, alcohol on breath, or visible physical signs of physical illness are relevant here, even if a physical. Important: You're not routinely expected to carry out a physical examination. However, if you think this is necessary and relevant, you should ensure that you have got the appropriate consent and follow the guidance on the use of chaperones.

5 Testing details of any testing carried out (if none, please state 'no testing carried out'), interpretation of results. explanation of any anomalies. Important: Please refer to the chemical testing guidance. Informant history and third party evidence full details of the sources of information you consulted, details of the phone conversations, including the date and who you spoke to, any written correspondence as an annex to your report. Important: You should not contact anyone not listed on the consent form without getting the doctor's written consent.

6 Diagnosis This section should include a current diagnosis, using ICD-10: Reasoning for diagnosis Summarise your assessment and always include: elaboration/evidence for reaching the diagnosis and for eliminating potential ones. Also provide your opinion on: risk of self-harm/suicide, risk to others, risk of relapse. the doctor's level of insight into their health condition.

7 Opinion on fitness to practise Use this section to provide your opinion on the doctor's fitness to practise. Fit to practise generally Use this terminology if you believe the doctor is fit to practise medicine without restriction. Fit to practise with restrictions Use this terminology if you believe the doctor should continue to be able to work, but with limitations on their practice. Not fit to practise Use this terminology if you believe the doctor is unable to work in a clinical capacity at all. Please select your opinion on fitness to practise Use this section to support your opinion with reasoning, supporting information and evidence. Important: You should consult the guidance on giving an option on fitness to practise. Recommendations Use this section to provide your recommendations about the following. Please provide clear reasoning relating to the impairing condition: whether the doctor needs to limit or abstain from alcohol consumption, whether the doctor should attend support groups, if applicable, the future testing regime, whether the doctor needs to be restricted, regarding self-medication, including over-the-counter medication, whether the doctor's prescribing should be restricted for certain drugs, e.g. schedule 1-4 or generally. whether the doctor should be prevented from working as a locum, or doing out-of-hours or on-call. Please provide clear reasoning relating to their impairing condition.

8 Statement of truth 1 I confirm that I understand that my primary duty in written reports and in giving evidence is to the Committee, rather than the part who engaged me. 2 I have endeavoured in my report and in my opinion to be accurate and to have covered all the relevant issues concerning the matter which I have been asked to address. 3 I have endeavoured to include in my report those matters of which I have knowledge or of which I have been made aware that might adversely affect the validity of my opinion. 4 I confirm that there are not any reasons why the medical report should not be shown in full to the doctor. 5 I have indicated the sources of all information that I have used. 6 I have not, without forming an independent view, included or excluded anything that has been suggested to me by others. 7 I will notify those instructing me immediately and confirm in writing if, for any reasons, my existing report requires any correction or clarification. 8 I understand that: a b c my report, subject to any corrections before swearing as to it's correctness may form evidence to be given under oath or affirmation; I may be cross-examined on my report by a cross examiner who may be assisted by an expert; I may be subject to adverse criticism by the Committee if it concludes that I have not taken reasonable care in trying to meet the standards set out above. 9 I confirm that I have not entered into any arrangement where the amount of payment of my fees is in anyway dependant on the outcome of the case. 10 I confirm that insofar as the facts stated in my report are within my own knowledge, I have made clear which they are and I believe them to be true and that the opinions I have expressed represent my true and complete professional opinion. 11 I have no conflict of interest of any kind, other than any which I have disclosed in my report. 12 I do not consider that any interest have disclosed affects my suitability as an expert witness on any issue on which I have given evidence. 13 I will advise the party by whom I am instructed if, between the date of my report and the hearing, there is any change in circumstances which affect my answers to any of the above declaration. Signature Date Click here to remove the instruction fields when finished